Medical homelessness and candidacy: women transiting between prison and community health care

Abstract

BackgroundWomen in contact with the prison system have high health needs. Short periods in prison and serial incarcerations are common. Examination of their experiences of health care both in prison and in the community may assist in better supporting their wellbeing and, ultimately, decrease their risk of returning to prison.MethodsWe interviewed women in prisons in Sydney, Australia, using pre-release and post-release interviews. We undertook thematic analysis of the combined interviews, considering them as continuing narratives of their healthcare experiences. We further reviewed the findings using the theoretical lens of candidacy to generate additional insights on healthcare access.ResultsSixty-nine interviews were conducted with 40 women pre-release and 29 of these post-release. Most had histories of substance misuse. Women saw prison as an opportunity to address neglected health problems, but long waiting lists impeded healthcare delivery. Both in prison and in the community, the dual stigmas of substance misuse and being a prisoner could lead to provider judgements that their claims to care were not legitimate. They feared they would be blocked from care even if seriously ill. Family support, self-efficacy, assertiveness, overcoming substance misuse, compliance with health system rules and transitional care programs increased their personal capacity to access health care.ConclusionsFor women in transition between prison and community, healthcare access could be experienced as ‘medical homelessness’ in which women felt caught in a perpetual state of waiting and exclusion during cycles of prison- and community-based care. Their healthcare experiences were characterized by ineffectual attempts to access care, transient relationships with healthcare providers, disrupted medical management and a fear that stigma would prevent candidacy to health care even in the event of serious illness. Consideration of the vulnerabilities and likely points of exclusion for women in contact with the criminal justice system will assist in increasing healthcare access for this marginalised population.

‘Genuine doctor care’: Perspectives on general practice and community‐based care of Australian men experiencing homelessness

“…The perception that some general practitioners are over‐cautious, defensive and perhaps under‐qualified in managing participants' medical problems aligns with another Australian study in women prisoners which found a similar scepticism about general practitioner expertise in the area of addiction (Abbott et al, ). Perceptions (and perhaps the reality) of a general practitioner retreat from medical generalism is of concern because referring on to other medical specialist providers is a relatively ineffective strategy in homeless people, with their high rates of non‐attendance at subsequent appointments.…”

“…Admitting to the latter may have presented a more vulnerable, less self‐reliant and stoic image to other homeless people than participants were comfortable with. There is also some evidence that homeless clients constantly need to construct accounts which show themselves to be worthy of services (Marvasti, ), or legitimate ‘candidates’ for care (Abbott, Magin, Davison, & Hu, ). Episodic crises with life‐threatening illness or injury may lend themselves more readily to such accounts than subacute or chronic problems presenting to general practice, and to some extent the apparently dismissive attitudes of hospital‐based practitioners to both general practice and clients may perpetuate this bind.…”

“Imagine if I'm not here, what they're going to do?”—Health‐care access and culturally and linguistically diverse women in prison

“…In our study, barriers to access were perceived by some to be due to racism and discrimination. For women with a background of trauma and abuse, negative interactions with health‐care providers can have profound emotional impacts and difficulty accessing health care in prison can be interpreted as deliberate blocking of care . The pre‐existing relationships and rapport the peer interpreters had with both parties may have decreased some barriers to care.…”

“…Using an inductive qualitative approach, we conducted focus groups and individual interviews with CALD women and individual interviews with prison health nurses. This study was undertaken in connection with a larger project into health‐care transitions of women leaving prison …”

“…Health care in these correctional centres is delivered under a Board‐governed network under the state health department. It is predominantly a nurse‐led model of care, which requires patients to be triaged by nursing staff prior to seeing medical practitioners …”